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With the news this week that Deschutes County is moving back into the High Risk category for COVID-19, I wanted to send you all a note and ask you to please hang in there just a little while longer.  

Wearing your mask in public places, washing your hands regularly and continuing to physically distance are all critically important. Our local, state and national health care systems are in a race to vaccinate as many people as possible before the more contagious variants of COVID-19 push us into a fourth surge of infections. 

St. Charles and Deschutes County are vaccinating people quickly against the virus – more than 80% of residents ages 65 and older have received at least one dose of the vaccine here. Our partners in Jefferson and Crook counties are also vaccinating as quickly as vaccine supply allows – and they have stayed in the Lower Risk category for another two-week cycle, which is fantastic news. 

Unfortunately, with case counts up in Deschutes County, many of our local businesses will again feel the pain of scaling back their operations. I can’t imagine how difficult it is for our restaurants, gyms and other businesses to continually adjust their staffing in alignment with the latest COVID-19 restrictions. I’m grateful for their perseverance through it all.  

And, I want to encourage you to do what you can to help.

  • First – Make sure you have registered for your COVID-19 vaccine appointment at centraloregoncovidvaccine.com. It only takes two minutes to complete the registration process. Every Oregonian over the age of 16 will be eligible for the vaccine as of April 19. That means, RIGHT NOW is the time to register. Once you are registered, you will be contacted to make an appointment as soon as a dose is available to you. 
     
  • Second – If you have already been vaccinated, encourage others to do the same. All three vaccines, which are authorized by the FDA for emergency use, are safe and highly effective at reducing death and hospitalizations due to COVID-19. They also greatly reduce transmission of the virus – meaning the more people we vaccinate the quicker we can return to a more normal way of life.
     
  • Third – Support our local businesses in safe ways by ordering take-out, choosing to socialize outside or buying gift cards to be used at a later date. Your actions can make a difference in ensuring our Central Oregon communities not only survive the pandemic but continue to thrive when it is over.
     
  • Fourth – I’ve said it many times before and I’ll say it again – mask, wash and distance. We simply aren’t yet at a point where we can stop doing the things that we know reduce illness.

Every eligible Central Oregonian should be jumping at the chance to be vaccinated and help end this pandemic.  

Be sure to take your turn.  

Sincerely,

Joe

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A message from St. Charles President and CEO Joe Sluka and La Pine Mayor Daniel Richer:

When St. Charles opened the doors of its Family Care and Immediate Care clinic in La Pine in May 2018, it did so to bring health care services closer to home for people who live there and in other medically underserved areas like Sunriver, Gilchrist, Chemult and Christmas Valley.

The project was years in the making and made possible in large part by the La Pine community. Individuals, foundations and businesses came together to see health care expanded in the south county area and contributed more than $1 million to fund the clinic, which houses primary care, immediate care, radiology, lab, occupational and specialty services.

Demand for services in La Pine is high. In 2020, more than 20,000 patients visited the clinic, 7,000 of whom were seen in Immediate Care alone. And as more people are seen there, more are referred to St. Charles' Bend hospital for medical emergencies that warrant a higher level of care than what the clinic can provide. In 2020, 715 patients were referred to the Emergency Department, 95 of whom went by ambulance. 

The decision to activate 911 is made with the safety and well-being of patients top of mind. That’s why we became deeply concerned when the La Pine Rural Fire Protection District (LPRFP) enacted an ordinance—Ordinance No. 2019-03—attempting to charge care providers like St. Charles and the La Pine Community Health Center for what the LPRFP claimed were non-emergent ambulance transports. But these “non-emergencies” were patients with potentially life-threatening problems like heart attacks and strokes.

Recently, the fire district decided to review this ordinance and invited public comment. It received overwhelming opposition to the fire district’s fee-based model. This outpouring of resistance to the ordinance included submissions by the Central Oregon Independent Practice Association (COIPA), a group that represents independent providers in the region, the La Pine Community Health Center and one of the co-authors of this piece, La Pine Mayor Daniel Richer.  

You can read the public comments here.

This Thursday, the fire district board is scheduled to review and vote on a replacement ordinance, 2021-01. The proposed new ordinance would direct the fire district to bill care facilities for all 911 activations— not the patient’s insurance, as is standard practice. We strongly oppose this new ordinance, as we believe it could place La Pine health care services at risk.

While the clinic sees thousands of patients each year, it operates at a significant financial loss and has been subsidized by St. Charles as a service to the community. Sadly, if St. Charles is forced to pay for ambulance transports, the increased losses to provide care may prove so challenging that the health system will most likely be unable to keep the clinic open. 

St. Charles cares about the La Pine community and wants to continue to do our part to serve it. The people of La Pine deserve access to the health care services they need, which is why we think the fire district board should reject this ordinance and stop the harmful practice of billing care facilities for transports instead of patients’ insurance. The fire district has many means to fund itself that do not endanger community residents. It’s time they explore those other options.

If you live in one of the areas served by St. Charles' clinic and the La Pine Rural Fire Protection District, we encourage you to attend the fire district board’s next meeting on Thursday at 9 a.m. The meeting is virtual, and you must send your request for the Zoom link to [email protected] before 3 p.m. on Wednesday. 

We think your health is too important to jeopardize over a fire district funding issue.

 

Joe Sluka
President and CEO
St. Charles Health System

Daniel Richer
Mayor of La Pine

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In a world of their own: Caregivers use virtual reality technology to train for medical emergencies

Janice Schmidt is in another world.

The St. Charles Bend operating room she’s in isn’t prepped for surgery—equipment is shoved to the side and sitting idle—and no one else is there.

But in her virtual reality, the operating room is hopping as a team of doctors and nurses quickly react to what could become a catastrophic disaster.

With a headset strapped to her face and paddles secured to each of her hands, the clinical practice education coordinator is racing to extinguish a fire that erupted when a laser (used to repair the trachea of a patient) ignited a dangerously high level of oxygen. Schmidt has mere seconds in this timed scenario to reach for a bowl of water, extinguish the burgeoning blaze and peel back the patient’s surgical drape before it’s engulfed in flames.

This heart-thumping scenario is all too real—which is exactly the point

“We don’t want to just read a book,” she said. “We want to see it, do it, feel it. Virtual reality is a game-changer for reduction in fire risk.”

That’s why St. Charles Health System is joining the ranks of other West Coast health care providers like Stanford Health and UCLA Health that are using virtual technology to improve the quality of the clinical training they provide. Since January, more than 100 St. Charles doctors, nurses and technicians have completed their annual Joint Commission-required education on fire prevention via Health Scholar’s Fire in the OR virtual reality simulation.

In operating rooms, fire is an ever-present danger, said Sherie Ponting, interim perioperative educator. That’s because the three components of fire, known as the “fire triad,” are present in nearly all surgical procedures: an oxidizer, like oxygen or nitrous oxide; an ignition source such as a laser or electrocauterizing tool, and fuel, which can be anything from surgical drapes to gauze.

Through virtual reality training, Ponting said caregivers realize just how fast a fire can happen and how quickly they must respond.

Operating room fires are rare events—about 550 to 650 are reported each year in the United States—but surgical teams must be ready to quickly communicate and react to minimize harm to patients and themselves.

An operating room fire can be a “horrific error,” Ponting said. “A patient’s future care and ability to survive it is based on how fast you can react.”

While virtual reality is a cost-effective way to offer training, it’s also highly effective. Learners who use virtual reality fire simulation training performed 250% better than those who only had traditional didactic teaching methods, according to research cited by Health Scholars.

“It was awesome,” one St. Charles caregiver wrote in their feedback form after taking the Fire in the OR training. Another offered, “I truly felt stressed and recognize how quickly a fire can get out of control.”

Schmidt and Ponting said the response from caregivers has been so overwhelmingly positive that the health system plans to soon offer additional virtual reality simulations for other kinds of scenarios such as when a patient experiences malignant hyperthermia (a kind of severe reaction to drugs used for anesthesia) or precipitous delivery (the rapid delivery of a baby).

“If I save one life, one patient from being harmed, that’s enough,” Schmidt said.

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St. Charles Bend technical caregivers ratify first-time contract  

The approximately 150 technical caregivers at St. Charles Bend who are represented by the Oregon Federation of Nurses and Health Professionals voted yesterday in favor of ratifying their first-time contract

"We are so pleased the Bend techs agreed with the compensation philosophy St. Charles has in place for all of its non-contracted caregivers," said Hillary Forrest, director of Human Resources for St. Charles and a member of the bargaining team. 

The contract provides general wage increases and market adjustments for the first year that will bring the technical caregivers to the same wage level as St. Charles techs at other campuses. The wage package brings the technical caregivers up to the level of wages they would have already received if they had not voted to unionize in September 2019. The average increase is about 11%, which is consistent with increases received from 2019 through the first quarter of 2021 for non-contracted technical caregivers. Most OFNHP members did not receive wage increases during the bargaining process.  

“Our bargaining philosophy has been to ensure that all St. Charles caregivers are treated fairly – regardless of if they are unionized,” Forrest said. “We did not provide retroactive pay for the technical caregivers and we achieved our goal of ensuring this group of caregivers is compensated with the same processes and general increases as caregivers who are not part of a union."

During bargaining, the Bend techs missed out on a potential of four wage and market increases that others have received since the fall of 2019. After the first year, the contract follows the same wage methodology St. Charles already uses for non-contracted caregivers. 

In addition, the St. Charles team held firm throughout negotiations in its belief that all St. Charles caregivers should have a choice as to whether they join a union. The ratified contract is considered an “open shop” and allows current and future St. Charles Bend technical caregivers to choose whether they join the union and pay dues. 

Negotiations on the contract have been taking place since January 2020. St. Charles leaders and union representatives met more than 30 times to bargain the contract – all while dealing with a global pandemic and community-wide COVID-19 vaccination roll-out. The technical caregivers participated in a work stoppage that started March 4 even though the team had not yet had its first session with the federal mediator, which was already scheduled for March 10.   

“The wage proposal that was ratified by yesterday’s vote is the same proposal St. Charles put on the bargaining table before the technical caregivers went out on strike,” Forrest said. “As we have said multiple times, no one wins in a strike situation. We are pleased that OFNHP was willing to return to work so we could negotiate the last items in the contract to ensure no future disruptions to patient care.”

About St. Charles Health System

St. Charles Health System, Inc., headquartered in Bend, Ore., owns and operates St. Charles Bend, Madras, Prineville and Redmond. It also owns family care clinics in Bend, La Pine, Madras, Prineville, Redmond and Sisters. St. Charles is a private, not-for-profit Oregon corporation and is the largest employer in Central Oregon with more than 4,500 caregivers. In addition, there are more than 350 active medical staff members and nearly 200 visiting medical staff members who partner with the health system to provide a wide range of care and service to our communities.

                                                                        ###

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For a brief moment on Wednesday this week, our Bend hospital had zero inpatients with COVID-19. It’s the first time we have hit that particular milestone since June 3 of last year. 

Although as of this morning our inpatient COVID-19 number was back up to one, it’s still a moment worth celebrating. 

We have come a very long way in our COVID-19 fight. 

At times it has felt like a never-ending battle. And while it isn’t over, I’m so very proud of our St. Charles team and our entire Central Oregon community for how we have come together to face this global pandemic. 

We have washed, we have masked and we have distanced – and will continue to do so – and these actions have undoubtedly saved lives. As our county risk levels decline and our worlds are opening back up, I have so much hope because of the most important tool in our COVID-19 fight: vaccinations. 

To date, along with our county public health and National Guard partners, we have given more than 50,000 COVID-19 vaccinations and are a leader in the state in terms of how many people we have vaccinated over the age of 65 per capita. 

While it is still too soon to draw any definitive conclusions, it appears our vaccine strategy is working. The average age of patients hospitalized at St. Charles Bend in March has declined compared with those hospitalized in January. This is a trend we hope to see continue as vaccinations become available to all Oregonians by May 1. 

My ask of you today, no matter your age or underlying health conditions, is that you pre-register for your COVID-19 vaccine. Visit centraloregoncovidvaccine.com and spend just two minutes completing the registration form. When you are eligible and we have a dose for you, we will send you a unique link to book your vaccine appointment.

Once you have pre-registered yourself, please share the link with others. Help us spread the word. If you are able, register those who don’t have access to a computer or need technical assistance. I am confident that just as we have pulled together to fight COVID-19, we will pull together as a community to ensure every eligible Central Oregonian who wants a vaccine is able to get one in the next few months. 

Thank you, as always, for your continued support. 

Sincerely,
Joe

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LSVT is a scientifically researched, high-intensity therapeutic intervention to improve motor coordination and voice production in individuals with Parkinson’s disease and other neurological disorders.

LSVT LOUD Speech Therapy can benefit the patient by:

  • Increasing vocal loudness
  • Improving articulation and speech intelligibility
  • Improving intonation
  • Improving facial expression
  • Creating changes in neural functioning related to voice and speech

Patients attend 16 one-hour sessions of Speech Therapy. One-on-one individualized sessions occur four consecutive days a week for four weeks. Additionally, patients will complete daily homework practice and carryover exercises.

LSVT BIG Physical and Occupational Therapy can help the patient achieve:

  • Faster walking with bigger steps
  • Improved balance
  • Increased trunk rotation
  • Improvements in daily activities (getting out of bed, getting dressed, etc.)
  • Improved standardized motor scores

Patients attend 16 one-hour sessions of combined Physical and Occupational Therapy. One-on-one individualized sessions occur four consecutive days a week for four weeks. Additionally, patients will complete daily homework practice and carryover exercises.

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OFNHP and St. Charles reach agreement, strike to end

The union and the hospital have come to an agreement that ends the strike and ensures that further negotiations will proceed effectively while patient care remains the focus.

BEND, Ore.—On Friday, March 12, technical caregivers who are represented by OFNHP and St. Charles Health System leaders came to an agreement that would end the strike and return therapists, technicians, and technologists to work on Monday, March 15. This agreement ensures the two parties will bargain over several days to secure a contract by March 31, addressing key issues that were discussed at a recent bargaining session. The agreement came together as both parties believe patient care is and should be the top priority, the strike has been distracting and difficult for all involved and it is in everyone’s best interest to return to the table and continue bargaining.

Further updates on ongoing contract negotiations will continue to be shared as upcoming sessions occur. The federal mediator has been very helpful and will continue to guide bargaining sessions through the end of the month. We look forward to building on this partnership to approach our collective challenges with dynamic solutions that will result in a fair contract.

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(NOTE: According to caregivers familiar with his case, there is zero evidence linking Dale Cheney’s medical incident, described below, to the COVID-19 vaccine he received earlier in the day. He just happened to be at the vaccine clinic when the incident occurred.)

Thousands of Central Oregon seniors have gone through the switchbacking vaccine line at the Deschutes County Fair & Expo Center over the past several weeks.

“Most days, it’s pretty uneventful,” said Dr. Matthew Slater, a cardiothoracic surgeon with St. Charles and one of many physicians who have volunteered to provide medical staffing for the fairgrounds COVID-19 vaccine clinic. Their job, typically, is to keep an eye out for people having trouble standing or moving through the line, to answer questions prompted by a pre-shot screening process and to respond when a patient has a reaction to a vaccine.

“That’s 99.9% of what we do there,” Slater said, “and then the rest is true medical emergencies.”

Medical emergencies have been rare so far, but they’re certain to happen, given the sheer number of people expected to be vaccinated at the clinic over the next few months, said Bo Miller, St. Charles’ medical director of provider informatics.

“We want to vaccinate as many people in Central Oregon as possible in the clinic,” he said. “When you have thousands and thousands of people, many of them elderly or with pre-existing conditions, the probability of a serious medical event unrelated to the actual vaccine is very real. We accounted for that and have a system to handle emergencies, no matter how uncommon they are.”

To date, St. Charles has spent around $250,000 on the vaccine clinic, Miller said, stocking medical supplies, upgrading the WiFi, paying for interpretation services and incurring other expenses to ensure patients are as safe as possible during their visit.

“We want people to be confident they can come here, get their shot and go home, and we’re watching out for them every step of the way,” Miller said. “If something goes wrong, we’re as prepared for it as we can be.”

DALE’S STORY

Dale Cheney of Redmond was scheduled to get his second dose of COVID-19 vaccine at 8:30 a.m. on Feb. 18. But he was up and ready to go by 7 a.m.

“I told him he should go ahead and go if he wanted to,” said Dale’s wife of 63 years, Judy. “So he left, and he had his cane with him because his back always bothers him if he has to stand for a while.”

Judy, 84, didn’t think anything of sending Dale to his appointment on his own. “He was in excellent health,” she said.

Dale, 86, arrived at the fairgrounds to find a line of about 50 people waiting to enter, Judy said, but a man near the front of the line saw his cane and invited him to jump in ahead of him. Once inside, Dale was escorted past the switchback section of the process and taken directly to a vaccination table, where he received his shot, she said.

From there, Dale walked to the respite room and took a seat to wait 15 minutes to make sure he didn’t have a reaction to the vaccine. After about five minutes, he looked up, Judy said, and made a mental note of how long he’d been there.

And that’s when Makena Forestell, a combat medic with the Oregon National Guard and a pediatric medical assistant at Mosaic Medical in Bend, heard Dale’s cane hit the linoleum floor.

“It drew our attention to him as he collapsed,” said Forestell, who was standing just a few dozen feet away. “We ran over to him, and when I saw other people initiating First Aid and blood all over his face, I went to grab gloves and gauze.”

Cheney had suffered a heart attack — unrelated to the vaccine he’d just received — and tumbled forward out of his chair, landing on the floor and breaking his nose. The first people to reach him were Forestell and Tiffani Soliz, a combat medic with the Guard and a medical assistant for Mosaic Medical in Redmond who, according to Forestell, “took charge of the situation immediately” by starting CPR and calling for an automated external defibrillator (AED) when she couldn’t get Cheney’s pulse. Soon, they were joined by paramedics from Redmond Fire & Rescue, as well as Slater, who immediately recognized Cheney’s affliction.

‘HE WAS DYING’

“I’ve seen a lot of dying people, unfortunately, in my career, and he was dying,” Slater said. “He was grey. He was struggling to breathe. He was clearly having what I thought was a cardiac event.”

The group worked to clear Dale’s airway and administered CPR while Forestell attached the AED to his body. After one shock and more CPR, a second shock — combined with a dose of epinephrine — brought Dale back to life, Slater said. He was then transferred to St. Charles Bend for further evaluation and treatment.

A week later, all involved were quick to credit others for the save. Soliz said a sheriff’s deputy did a good job of keeping onlookers away and helping to protect Dale’s privacy. Slater praised the “spectacular” work of the Guardsmen and the Redmond paramedics. Soliz also said the impromptu team worked incredibly well together. “I’ve seen established ER teams that didn’t work together as well as we did,” she said.

“Thankfully, this happened in a place surrounded by doctors, medics, paramedics, EMTs and nurses,” said Forestell. “We were able to get to him quickly and it worked out alright.”

For Judy, her husband’s good fortune started earlier in the day.

“The way it all came together — that he went an hour early, the man who called him to the front of the line — it all led to him being in that chair at that moment,” she said. “Had it been just a minute’s difference, he could’ve fallen while he was walking. He could’ve had it in the car. He could’ve died at home.”

THE SYSTEM WORKED

Besides staffing the clinic with the right people and positioning them effectively, Miller and a group of St. Charles caregivers worked diligently before the clinic opened to make sure the right equipment, the right medications and the right protocols are in place and ready for the most likely medical emergencies. They brought in a fleet of golf carts to transport mobility challenged people from the parking lot to the front door, and they placed wheelchairs strategically throughout the facility. They even closed half the bathrooms to give people less space to roam between their shot and the respite room.

Not all of those factors directly affected Dale Cheney’s incident, but it’s that kind of planning and attention to detail that put him in the right place at the right time and surrounded him with the resources that saved his life.

“It’s never a good day to have a heart attack, but if you’re going to do it, it’s best to do it in front of a system designed to rescue you,” Slater said. “The system is designed to give us the best chance of saving somebody, and this is evidence that it worked.”

EPILOGUE

Dale Cheney was discharged from the hospital a week after his heart attack and had a few days of feeling good at home, said Judy, his wife. But then he stopped eating and started losing strength, and on the first day of March, he went back to the hospital, where he was diagnosed with pneumonia.

He passed away late in the evening on March 5.

Judy is devastated, and she is also grateful to the people who cared for her husband that day at the fairgrounds. She’s thankful that their life-saving efforts gave her a couple more weeks to talk to Dale and take care of him.

She said she has asked God why He saved her husband only to take him a short time later, and she thinks she knows at least part of the answer.

“What happened to him that day was a miracle,” she said. “And we need to tell people about it to let them know that miracles do still happen.”

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A tiny seed is having a big impact on breast cancer care.

In partnership with Central Oregon Radiology Associates (CORA), St. Charles Cancer Center has begun using Magseed—a tiny, iron oxide “seed” that is implanted in a cancerous breast tumor to mark its location for surgery. Equipment needed to use Magseed was purchased with money from Sara's Project, a St. Charles Foundation fund dedicated to easing the challenges of breast cancer for people in Central and Eastern Oregon.

The Magseed is a substantial improvement over the metal wires that were formerly used to guide surgeons to tumors that are otherwise too small to find, said Dr. Kelly Hewitt, a University of California San Francisco fellowship-trained breast surgeon who joined the Cancer Center in October.

“As you can probably imagine, that can be fraught with issues,” said Hewitt, who prior to her fellowship worked as a general surgeon in Newport, Ore.

The thin wires, which usually had to be placed the day of surgery, could sometimes become dislodged when the patient traveled from the radiologist’s office to the hospital, or in the operating room, she said. And because the wires could be unwieldly, they had to be taped to the patient’s breast until she was in the operating room.

“From a system standpoint, it’s also a scheduling nightmare because they have to put the wire in at a certain time and coordinate it with surgery, etc.,” she said.

Placed by a radiologist in the breast tissue, the radiation-free Magseed marker won’t move or break, and can be placed days, weeks and even months ahead of surgery, Hewitt said. During surgery, she waves a wand-like localization device over the breast that guides her to the seed, targeting where the incision needs to be made.

“It really lets me pick my incision based on aesthetics and safety,” Hewitt said. “Sometimes the wire can kind of dictate where you have to go, but with the seed, it gives you more flexibility.”

Hewitt said she has even implanted the Magseed—which is so small it can’t be felt by the patient—in lymph nodes that need to be removed as well.

The only fellowship-trained breast surgeon in Central Oregon, Hewitt said she is excited to be able to use this new technology to improve care for patients.

“It’s all about perfection and doing something that is both oncologically safe—so, getting all of the cancer out—but then also making it look as nice as possible,” she said. “So, having the best aesthetic outcome in combination with the best oncological outcome.”

Heads up: Dr. Kelly Hewitt will present "Breast cancer in 2021: Diagnosis to survivorship" at our next installment of Doc Talks on March 29.

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In recent weeks, media outlets, health care organizations and others around the world have been marking the one-year anniversary of COVID-19’s unwelcome arrival into our lives.

What a year it has been.

When I think back, I cannot remember when or where I first read about this new novel coronavirus, which started in China in late 2019 and spread to the United States in January of 2020.

What I can remember is the day the first presumptive positive case of COVID-19 was confirmed in Central Oregon: March 11, 2020. I remember attending a hastily organized mid-day meeting, where the overriding mood was not one of worry or panic, but of confidence and resolve. We had been preparing for that moment for months, and we knew that while the disease was unpredictable and the future was uncertain, our health system was ready to handle it.

I also remember watching my colleague, Dr. Jeff Absalon, and other local officials speak at a press conference that afternoon. “This,” said Dr. Absalon, St. Charles’ chief physician executive,  “is what we do.”

To be clear, he was not talking about holding press conferences. He was talking about caring for people who are sick.

That is what we do here at St. Charles, every single day. It is our commitment to ourselves, our commitment to each other, our commitment to our communities and our commitment to you.

Of course, there have been tough stretches over the past year. Preparing for and responding to COVID-19 has been a massive operational undertaking for our health system. It has dealt a financial blow to our organization. It has changed the way we do just about everything, from the bedside to the board room and all points between. And it has certainly tested our frontline caregivers and our first responders.

Have there been uneasy moments? Definitely. We are human beings, after all. But again and again over the past year, I have seen our people rise to the challenge, whether that challenge is figuring out how to quadruple a hospital’s patient capacity without expanding its footprint or how to give a dying woman the birthday celebration she deserves, even in isolation. Now, they’re heavily involved — alongside Deschutes, Crook and Jefferson counties and the Oregon National Guard — in the complicated regional effort to end this pandemic by vaccinating as many people as possible as quickly as possible. And they’ve done it all during a time of unprecedented upheaval in both their professional and their personal lives.

I have said it before and I’ll say it again: I feel incredibly proud and fortunate to lead the 4,600 caregivers who make St. Charles Health System such a great place to provide and receive care. Through a year of dizzying ups and downs, they have been a steadying force every step of the way.

Sincerely,
Joe

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